Is laparotomy for staging early ovarian cancer an absolute necessity?

STUDY OBJECTIVE: To demonstrate that palpation of the omentum, mesentery, and intestine can be omitted from the laparoscopic staging of stage I carcinoma of the ovary. DESIGN: Retrospective analysis of 223 women with stages III and IV ovarian cancer treated by laparotomy. SETTING: Gynecological Oncology Clinic, M. Sklodowska-Curie Memorial Cancer Institute of Oncology, Warsaw, Poland. INTERVENTIONS: Observation of macroscopic spread of tumor to areas accessible to laparoscopic inspection versus spread to areas inaccessible to laparoscopic evaluation. MEASUREMENTS AND MAIN RESULTS: Macroscopically detectable disease in the areas easily accessible to laparoscopic inspection was present in all cases of metastases to the mesentery, omentum, or intestine. CONCLUSION: The diagnosis of FIGO stage I ovarian cancer can be made with confidence if laparoscopic inspection of certain areas reveals no evidence of metastases.

[New perspectives in color ultrasound in breast diagnosis]. / Neue Perspektiven des Farb-Ultraschalls in der Mamma-Diagnostik.

In recent years, ultrasound has become established as part of the diagnostic evaluation of breast tumours. Not replacing, but complementing mammography, ultrasonic investigations increasingly represent a sensitive means of early diagnosis. Thermography, on the other hand, has proved of relatively little value and doesn't play a significant role today. Lately, Colour Doppler sonography has been used for differentiating tumour-associated blood supply patterns--however, sensitivity and specificity were not as high as initially expected. Colour spectrum analysis of local findings in comparison to the remaining glandular tissue, however, seems to be a promising method in the differentiation of ultrasound findings of uncertain tumour status. A fibroadenoma shows no significantly different colour density as compared to surrounding tissue. In carcinoma, on the other hand, one regularly finds a hyperintensive zone with sharp margins. In 70 patients, who had breast tumours, we attempted the differentiation of benign and malignant findings with the help of colour spectrum analysis. Postoperatively, these results were validated by histology. With the exception of one mesenchymal tumour, the Doppler diagnosis was identical to the histopathological findings.

[Laparoscopic treatment of ovarian tumors in menopausal women]. / Traitement coelioscopique des tumeurs de l'ovaire chez la femme ménopausée.

OBJECTIVE: The authors report their experiences in the laparoscopical therapy of ovarian tumours with 94 postmenopausal women. STUDY DESIGN: The patients were treated in the Department of Gynecology at Göppingen Medical Center from March 1, 1992 until December 31, 1993. Tumour marker CA 125 was not within normal limits (< 35 U/ml) in all patients. Preoperatively all findings were verified by ultrasound examination. In some cases, cysts were single-chambered, smooth-bounded or without endovegetations. Choice therapy has been bilateral adnectomy without opening the ovarian cyst and without trauma to the ovary capsula. Adnectomy was performed by bipolar coagulation and sharp preparation. In every case the specimen was positioned intact in a "Lap-Sac" and then removed via second puncture. In case of ultrasonographic or laparoscopic-macroscopic conspicuous findings an obligatory fast microscopic random sample was performed. RESULTS: In one case the microscopic test sample revealed carcinoma of the ovary--the operation was terminated by standard laparotomy. No other cases showed signs of malignancy. There were no peri- or postoperative complications. The average operation lasted 35 min (20-80 min), all operations were performed without significant blood-loss. Usually the patients were discharged at the 4th to 6th postoperative day. CONCLUSION: This operation-technique guaranteed "oncological aseptic" results at any time of operation. Therefore you can waive the standard laparotomy for the benefit of laparoscopy in many elderly patients even with suspicious findings.

[Internal urinary diversion in complicated pregnancy-induced hydronephrosis]. / Untersuchungen zur internen Urinableitung bei komplizierter schwangerschafts-bedingter Harnstauung.

In 14 women with sympthomatic hydronephrosis of pregnancy (calix diameter 1-2.6 cm) an internal urinary drainage was carried out during the second half of pregnancy. Retrograde stenting was performed following cystoscopy in all cases. Follow up examinations were taken weekly for the first two weeks and further on biweekly. Primary stenting was possible in 12 out of 14 cases and in 2 patients dilatation of the ureteral orifice was necessary. 11 out of 14 patients suffered from complications consisting of severe dysuria (9x), urinary tract infection (7x), persisting lumbar pain plus catheter lumen obstruction (6x each) as well as catheter dislocation (3x). Long term follow up showed that urinary tract obstruction was relieved by stenting in only 6 out of 14 patients. Sufficient urinary drainage by so called double-J-ureteral stents was achieved in less than half of the cases. Moreover, there was a complication rate of more than 75%. Taking these results into consideration, internal drainage of complicated pregnancy hydronephrosis needs careful evaluation.

[Value of vaginal ultrasonography in noninvasive assessment of the endometrium of the postmenopausal uterus]. / Der Stellenwert der Vaginosonographie in der non-invasiven Beurteilung des Endometriums am postmenopausalen Uterus.

The endometrial carcinoma shows an increasing incidence and represents today the most frequent malignoma of the female pelvis. Until now all techniques of detection of this carcinoma or its precursors are invasive and thus are not suitable for screening investigations. Vaginosonography, as the first non-invasive diagnostic method, now supplies knowledge about the state of the endometrium. At the Gynaecological Department of the University of Homburg/Saar, West Germany, 221 patients had been preoperatively subjected to vaginosonography before they underwent surgery. Sonographical and histological findings corresponded in atrophic endometrium in 82%, in regular, perimenopausal endometrium in 91%, in endometrial polyps and hyperplasia of the endometrium in 56%, and in endometrial carcinoma in 79%. With regard to the detection of endometrial cancer, a specificity of 96%, a sensitivity of 93%, a positive predictive value of 79% and an accuracy of 96% were established. Thus, according to our experience, vaginosonography represents a valid, non-invasive diagnostical method as a suitable instrument for screening the endometrium.

[Pregnancy-induced changes in adrenergic receptors]. / Schwangerschaftsbedingte Veränderungen adrenerger Rezeptoren.

In the 24th and 26th week of pregnancy and also 6 weeks post partum, n = 32 pregnant women were evaluated for the concentration of adrenergic receptors on blood cells by radioligand binding assay and an isoprenaline stimulation of the beta-receptors. The concentrations of estradiol and progesterone in serum were also determined and nephrosonography was carried out. The stimulation and concentration of the beta-receptors were significantly higher during pregnancy than post partum. The alpha-receptors displayed contrary alterations: Here, the concentration evaluated during pregnancy was considerably lower. No connection was determined between the progesterone level in serum and the extent of the receptor alterations. However, one was found with the estrogen level and the dilatation of the upper urinary tract: Pregnant women with pronounced alterations above the median showed a distinct decrease of estradiol and a marked dilatation of the kidney collecting system. Alterations in the adrenergic receptors can therefore be determined during pregnancy. The extent of the receptor fluctuation is connected to the estradiol concentration in serum and the dilatation of smooth muscle hollow organs.

[Slit drainage versus Redon drainage in a clinical comparison--initial experiences with a new kind of wound drainage system]. / Slitdrainage versus Redondrainage im klinischen Vergleich--erste Erfahrungen mit einem neuartigen Wunddrainagesystem.

In a prospective, randomised study we compared the clinical properties of the established Redon drain with a new type of drain called "slit drain". Both types of drains were examined regarding the amount of drained fluid, the time elapsing until removal of the drain, the frequency of occlusion of the lumen as well as the patient's pain and the required force at extraction of the drain. The statistical analysis showed both drains to have equal abilities in draining of fluid if they were used under vacuum conditions. If used as nonsuction drains, the new device was able to drain more fluid than the established type of drain (p less than 0.05). Statistically relevant advantages of the slit drain were seen in a lower rate of obstruction of the lumen, a higher amount of drained fluid (as non-suction device) as well as an easier and less painful extraction.

[Midazolam and pethidine/promethazine for intramuscular premedication]. / Midazolam und Pethidin/Promethazin zur intramuskulären Prämedikation.

The main reason for premedication is the reduction of preoperative stress. Despite the proven fact that benzodiazepines best reduce preoperative stress, combinations of opioids and neuroleptic drugs are preferred for premedication by many on reviewing the journal Der Anaesthesist. This double-blind study was performed to investigate midazolam and meperidine/promethazine for intramuscular premedication. Method. 60 patients undergoing minor gynecological surgery were randomly assigned to receive either 5-7.5 mg midazolam or 50-75 mg meperidine and 25-50 mg promethazine intramuscularly 30-90 min before surgery. Anxiety, depression, and asthenia were assessed by the patient before and after premedication but before induction of anesthesia using visual analogue scales and a nominal scale. Sedation was assessed by an observer. Heart rate and blood pressure were the physiological stress parameters. Parameters of acceptance and side effects were registered perioperatively. Results. Midazolam had a significantly better anxiolytic and antidepressive effect. There were no differences in the other parameters except for adverse effects. Meperidine/promethazine produced significantly more side-effects than midazolam. The parameters of acceptance assessed the day after surgery were comparable. Conclusions. We conclude from these results that anesthesiologists still premedicate with meperidine/promethazine because the patients accept this premedication very well when asked the day after surgery. Nevertheless, premedication with midazolam provides significantly better anxiolytic and antidepressive effects with significantly less side-effects. Therefore, midazolam should be preferred to meperidine/promethazine for intramuscular premedication.

[Effect and side effects of oral morphine, lormetazepam and placebos as premedication]. / Die Wirkung und Nebenwirkung oralen Morphins, Lormetazepams und Plazebos zur Prämedikation.

In 60 patients undergoing a curettage in thiopentone induced inhalation anaesthesia with enflurane and N2O/O2 = 2:1, the effects of oral premedication (2 h before anaesthesia) with 30 mg morphine (MST 30) (n = 21), 1 mg lormetazepam (Noctamid) (n = 19) and placebo (n = 21) on psychological (anxiety, depression and asthenia), physiological (blood pressure, heart and respiratory rate) and pain parameters (visual analogue scale, analgesic consumption) were investigated. The study design was single blind, randomized. Before premedication the three groups did not differ in one parameter and so were comparable. MST 30 had a significantly better anxiolytic, Lormetazepam a significantly better antidepressive effect than the compared substance. There were no differences in blood pressure and heart rate. In contrast to lormetazepam and placebo after MST 30 there was no increase in the respiratory rate which can be explained by the anxiolytic stress reducing effect. There was no difference in peri- and intraoperative pain parameters, probably due to the type of surgery. Nausea and vomiting occurred more frequently after MST 30, but there was no significance. A higher rate was probably prevented by the application of transdermal scopolamine the day before surgery. The indication of analgesics (opiates) for premedication is discussed taking the controversy into account. The results of this study show that oral morphine (MST 30) has an anxiolytic effect, one of the most important effects a premedication should have. Further studies should investigate in which types of surgery the analgesic effect of MST 30 is peri- and intraoperatively relevant, so that advantages compared to e.g. Flunitrazepam, Midazolam or Lormetazepam in a higher dosage could be expected.

[Conization of the uterine cervix. A study of 900 cases]. / Die Konisation der Cervix uteri. Eine Studie über 900 Fälle.

In the years 1968 till 1982, 900 conisations of uterine cervix were performed, 90% of which were diagnostic interventions. During the follow-up period, the mean age of the patients with carcinoma in situ decreased 4 years, the mean age from patients with microcarcinoma 3.2 years. In 64% the conisation was carried out due to a positive or suspekt smear. Conisations, performed during pregnancy, were not associated with any additional complications for mother or child. Taking a big conus resulted more often in a total extirpation of the neoplastic changes, without increasing the complication rate. The average hospital stay was 8.7 days. It was only prolonged in patients with secondary hemorrhage. 33% of all neoplastic changes were extirpated totally. In 85% of the women who had follow-up only after incomplete extirpation of the neoplasia by conisation, there was no recurrence. The rest did show the neoplasia again, often in a more serious way. The overall complication-rate was 7.4%.

[Cost-benefit studies of 2 equivalent forms of therapy in cervical cancer in the pretherapeutic T 1b stage]. / Kosten-Nutzen-Untersuchungen zu zwei gleichwertigen Therapieformen beim Kollumkarzinom im prätherapeutischen Stadium T 1b.

Patients suffering from a collum carcinoma stage T 1b can be treated either by operation according to Wertheim and Meigs, or by radiotherapy. The results with regard to post operationem complications, five-year-survival and recidivation are equivalent in both methods. Therefore, an analysis of the indirect benefit and the costs of both therapies was performed. Surgery was superior to radiotherapy in all analysed dimensions of indirect benefit. Over and above this, expenses for an operation were 2.7 times lower than for radiotherapy.

Carcinoma of the cervix stage T1b. A 15 years review of 256 cases.

256 patients of the years 1965-1979 who suffered from collum carcinoma stage T1b were reviewed. Most of the neoplasmas were squamous cell carcinoma (81%). By tumor screening only 21% of the carcinomas were detected. The treatment was in most of the cases a radical hysterectomy (Wertheim-Meigs). Postoperative radiotherapy was performed in cases of poor differentiated carcinoma of if lymphatic nodes had been occupied by the tumor. Thus only 43 patients had no radiotherapy. A 5 year-follow-up was possible in 151 cases. Women older than 40 year showed a better prognosis than younger women. Patients treated only by radiotherapy had a five year survival rate of 88%. No difference in prognosis was observed, if radiotherapy was additionally performed. There was no significant difference of severe complications in either forms of treatment.

[Peridural morphine analgesia for the control of tumor-induced pain in gynecologic cancer patients]. / Peridurale Morphin-Analgesie zur Bekämpfung von tumorbedingten Schmerzen bei gynäkologischen Karzinompatientinnen.

22 gynecological patients suffering from considerable tumor pain in an advanced carcinoma stage had a continuous peridural anaesthesia. 18 patients reported a very good and 4 patients a sufficient analgesia. The average morphine dose per day was 14 mg. The indwelling catheters remained on an average 27 days in site. Side effects, which could be related to the morphine PDA, occurred in one case.

[Cervical carcinoma in the T1b stage. Therapy, complications and prognosis]. / Das Zervixkarzinom im Stadium T1b. Therapie, Komplikationen und Prognose.

Records of 256 patients with carcinoma of the cervix uteri stage T1b from the years 1965-1979 were reviewed retrospectively. By screening programs only 21% were detected. Most of the neoplasms were squamous cell carcinoma (81%). The majority of the patients was treated surgically most frequently by radical hysterectomy (Wertheim-Meigs). If the carcinoma was poorly differentiated and/or lymphonodi were positive postoperative radiotherapy was added. Thus only 43 patients had no radiotherapy. 5 year survival rate could be studied in 151 patients. 89% survived 5 years or more following primary treatment. Older women (over 40 years old) showed a better prognosis than those below 40. Patients treated by radiotherapy alone survived 5 years in 88 per cent. Patients treated by radical hysterectomy had a five year survival rate of 94.6%. No difference in prognosis was observed, if radiotherapy was added. There was no significant difference in the frequency of severe complications in both kinds of treatment. The rate of recurrencies was 9.4 per cent.

[Histological and cytological changes in women using intrauterine contraceptive devices (author's transl)]. / Histologische und zytologische Veränderungen bei IUD-Trägerinnen.

We studied 175 surgically removed uteri containing intrauterine devices. As described, we found that inert and bioactive devices produced diverse histological changes. Cytological changes of the glandular and squamous epithelium are mentioned and evaluated.

PIP: 175 surgically removed uteri containing IUDs were studied. It was found that inert and bioactive devices produced diverse histological changes. Cytologic changes of the glandular and squamous epithelium are mentioned and evaluated. (Authors' modified)